Critical Care Minutes

This has been a hot topic surrounding not only the transplant community but also the critical care and anesthesia world. It is not uncommon for Dr. Sanjay Gupta or Dr. Oz (the premier TV celebrity docs) to come on national television usually on major broadcast shows such as Oprah and describe fantastic success stories that describe recent transplanted patient’s lives. Of course it is great that these patients did well, but this doesn’t mean they ALL do well!! This is certainly evidenced by some of the “expanded” criteria patients we take care of in the ICU.

Certainly we should be doing our best to give as many patient’s a chance at a new life – at a new liver. But the patient’s need to be better informed of the risks and alternatives and given realistic expectations. “Mr. Patient it isn’t gonna be like Dr. Gupta described – you won’t be as lucky but don’t worry you will have a new LIVER.”. Sometimes they might choose a shorter survival when faced with near definitive trach/dialysis/nursing home or chronic vent support situation that many of the high risk patients face today. It isn’t all about 28 and 90 day mortality rates! It should be about QUALITY OF LIFE.

November WSJ article was an excellent look at the exact phenomenon. Take a look at it here
“DOING A VOLUME BUSINESS IN LIVER TRANSPLANTS”

So the next couple of posts will be dedicated to revisiting the criteria for liver transplant and a detailed look at the “Expanded” criteria opened up for high risk patients to increase recruitment of potential recipients. Let us see if this is really for the patient’s or for numbers of the transplant center. Stay Tuned!

The Endocrine Society is an multi-national, multidiscipline organization with ~14,000 members from over 100 countries. It was founded in 1916 and publishes 4 peer-reviewed journals. On March 26th, 2009 immediately after the NICE SUGAR study was published they released a statement which supports loosening glycemic control in ICU patients may now be more prudent.  They state that we should be targeting glucose values between 144-180 mg/dl “until we better understand the reasons for these somewhat counterintuitive findings.”
Below is an excerpt from the statement which can be viewed in its entirety here   –>

The Endocrine Society commends the NICE-SUGAR investigators for producing an important and provocative addition to the medical literature and draws the following conclusions and recommendations from their data. First, near-normalization of blood sugar does not clearly improve outcomes in all critically ill hyperglycemic ICU patients, and there is even a suggestion that such an approach may worsen outcomes. Second, looser control of hyperglycemia, i.e., target blood glucose of 144-180 mg/dl, is a reasonable, and perhaps preferable, option in this particular group of very sick patients. Third, it is essential to assess clinically meaningful outcomes, such as mortality, as well as surrogate or intermediate endpoints, such as blood sugar level, in studies of diabetes treatment as the NICE-SUGAR study has done; improvement of blood sugar control may not always translate to better clinical results.

Here is another fantastic ICU 2.0 resource. You can subscribe to these podcasts in iTunes or listen to them directly on the website. Dr. Jeffrey S. Guy has taken topics he discussed on teaching rounds in the Burn ICU at Vanderbilt and brought them to you as onDemand solutions! It is these sort of resources that are inspirational for me and truly on the forefront of teaching in the 21st century. Well Done Dr. Guy! I hope you enjoy and become a subscriber (as I did).

BTW. Look out for the Critical Care Minutes podcast and vodcast series which will be starting up very soon. Stay Tuned!

You can now follow along with us by signing up for our twitter updates. Just click on the link below. Also you can always subscribe to the site with your favorite RSS reader. Stay tuned, exciting new ICU 2.0 features will be coming to the site very soon including the ability to join in our LIVE! web conferences. Click the logo to follow along!

This week’s issue of NEJM features another in a long debated series of trials that investigates the benefits of  “tight” vs “conventional” glycemic control in the ICU.  Is this the one that finally gives us the answer? Let’s find out…

The NICE-SUGAR Study Investigators are a multinational, multicenter and multidisciplinary collaboration. The primary objective of this trial was to find the optimal glycemic level for critically ill patients. Patients expected to stay in the ICU for >3 days were enrolled within 24 hours of admission to the ICU. They were randomized to either recive INTENSIVE (81-108 mg/dl) or CONVENTIONAL (<180 mg/dl) therapy. The primary endpoint was 90 day mortality (any cause / after randomization).

After enrolling 6104 patients, 3054 received intensive rx and 3050 received conventional rx. Groups were relatively well matched at baseline.  The major difference in primary outcome was a RRR of ~ 9% in the conventional group (24.5% vs 27.5%). This corresponded to an odds ratio of 1.14 (95% CI 1.02-1.28),  p=0.02. There was no differernce in the treatment effect when looking at medical vs. surgical patients.  Of note, severe hypoglycemia (<40) occured ~13x more often in the intensive group (0.5% vs 6.8%    p<0.001). No other significant differences upon subgroup analysis or secondary outcomes were found.

Read more…

Here is another excellent and thorough resource I found online in the blogger community that reviews several procedures including Central Line Placement, Thoracentesis, Paracentesis, Arterial Line, Lumbar Puncture, etc. The review is not video based but does have very detailed images used to illustrate the techniques as well as nice decriptive explanations. ClinicalCases.org is a free online case-based curriculum of clinical medicine and is one of the most popular medical blogs on internet. A lot of the information may not be relevant to the ICU but it is still a good resource for topic reviews. I would encourage you to browse the site and get your learn on Incidentally, this website has significant input from the Cleveland Clinic and the Case Western Lerner College of Medicine – The blog was developed by Dr. Vesselin Dimov (Internal Medicine, CCF).

ClinicalCases.org was featured in the British Medical Journal and Medscape.com, and was referenced several times in the medical education literature. The project is hyperlinked in the web sites of 11 medical schools in the U.S., Canada and Europe. This case-based curriculum was started by physicians at Cleveland Clinic and Case Western Reserve University (St. Vincent/St. Luke) Internal Medicine Residency Program for the purpose of medical education.

Check it out Clinicalcases.org.

Here is a link to the Procedural guides.